Rectal Bleeding

Jessica Cintolo

Scott Q. Nguyen, M.D.

Celia Divino, M.D.

Mount Sinai School of MedicineMount Sinai School of MedicineDepartment of SurgeryDepartment of Surgery

Ms. C

Ms. C is a 33-year-old female who presents to her primary care physician complaining of bloody bowel movements for the past 4 weeks.

History

What other points of the history do you want to know?

History, Ms. C Consider the following:

• Characterization of Symptoms

• Temporal sequence• Alleviating /

Exacerbating factors:

• Associated Signs & Symptoms

• Pertinent PMH• ROS• MEDS• Relevant Family Hx.• Relevant Social Hx.

History, Ms. C

Characterization of Symptoms and Temporal Sequence of Events• Patient noticed bright red blood in her stool

beginning 4 weeks ago, sometimes mixed with mucous. Her bowel movements have been loose but formed.

• She has approximately 3 bowel movements daily and often feels an urgent need to defecate.

• She has also noticed intermittent crampy abdominal pain and a decrease in appetite over the past month.

History, Ms. C

Alleviating/Precipitating Factors• Abdominal pain often worsens with eating• Nothing alleviates symptoms

Associated Symptoms• No Nausea or Vomiting• Decreased Appetite• Weight loss of about 10 lbs over past month

History, Ms. C

Has this happened before?• She has experienced abdominal pain and

bloody diarrhea twice in the past year but never lasting more than 2-3 days

Sick Contacts and Travel History• No known sick contacts

• No recent travel out of the country

Additional History, Ms. C

PMH• None

PSH• Appendectomy at age 9

Meds:• None

Additional History, Ms. C

Family History• Several family members have had “intestinal

problems” Social History

• Smoked ½ pack per day for 10 years until 2 years ago, social ETOH consumption, no other drug use

• Sexually active in monogamous relationship

What is you Differential Diagnosis?

Differential DiagnosisBased on History and Presentation

Inflammatory Bowel Disease• Crohn’s Disease• Ulcerative Colitis

Infectious Colitis Parasites: Strongyloidiasis, Amebiasis Rectal or Colon Cancer or Lymphoma Diverticulitis Radiation Enteritis Gastroenteritis

Physical Examination

What specifically would you look for?

Physical Examination, Ms. C

Vital Signs: T = 37.3, P = 86, BP = 110/76, RR = 14 Appearance: thin, pale, but in no acute distress HEENT: Sclera anicteric, mucous membranes pink and

moist Heart: RRR Lungs: mild rales at bases Abdomen: normoactive BS, non-distended, mildly

tender throughout, no guarding or rebound tenderness Rectal: stool in vault mixed with bright red blood, no

masses, no external anal lesions

Differential Diagnosis

Would you like to update your differential?

Laboratory

What would you obtain?

Lab Results

MCV = 82%

LFTs WNL PT/PTT WNL Stool O&P negative C. difficile toxin negative

6.710.9

32.3225 138 108

3.7 24.0

12

0.798

Laboratory Results-Discussion

Normal WBC – infection less likely Mild Anemia – likely from GI bleeding with

chronic blood loss given low MCV Electrolytes - Normal C. difficle toxin negative - sensitivity is 80-99%

based on assay with specificity of 99% making infection with C. difficile highly unlikely

What are the Next Steps in Diagnosis and Management?

Further Diagnosis and Management

• Interventions?

• Imaging?

• Endoscopy?

Abdominal X-Ray

X-ray interpretation

• Normal Abdominal Film• No colonic dilatation• No signs of small bowel obstruction or ileus

Colonoscopy

What would you expect to see?

Colonoscopy: Findings & Discussion

Continuous inflammation of colonic mucous involving rectum and extending to the splenic flexure and into the early transverse colon

Mucosa is erythematous, edematous, and friable Pseudopolyps – inflammatory, non-neoplastic

mucosal projection Mucosal Biopsy demonstrates distortion of

architecture with crypt branching, crypt abscess containing inflammatory cells, ulceration; no granulomas

Final Diagnosis

Ulcerative Colitis

What next?

Medical Management for Mild-to-Moderate Ulcerative Colitis

5-ASA agents• oral and rectal preparations

Oral Corticosteroids 6-MP/Azathioprine

Medical Management, Ms. C

Ms. C is started on Sulfasalazine 1g TID and also given a course of steroids

Her symptoms improve dramatically over the next few days

She maintains Sulfasalazine therapy for disease control despite minimal symptoms

Ms. C returns

Ms. C now presents to the emergency department 3 weeks after completing the steroid taper. She began having crampy abdominal pain and bloody diarrhea 2 weeks ago increasing in severity over the past 5 days.

History, Ms. C Characterization of Symptoms and Temporal

Sequence of Events• Abdominal pain began gradually 2 weeks ago, was

intermittent and crampy, but now worsening in severity and constant

• Diarrhea also began 2 weeks ago. It was watery and mixed with bright red blood. Over the past 5 days patient has noted more blood in the toilet bowl.

• She has been having >10 Bowel movements daily• Today diarrhea is less than it has been the day

before

History, Ms. C

Alleviating/Precipitating Factors• She attempted to take over-the-counter anti-

diarrheal agents without relief• Patient feels worse with eating; she has avoided oral

intake for the past week Associated Symptoms

• Subjective fevers and chills• Dizziness, particularly on standing• Nausea, but no vomiting• No joint pain, no visual changes or eye pain

Physical Examination, Ms. C

V.S. T=38.7°C, BP=104/60 (seated), 90/50 (standing), HR=102 (seated), 116 (standing)

General: thin, uncomfortable HEENT: sclera anicteric, mucous

membranes dry, no oral lesions Cardiovascular: tachycardic, normal S1,

S2, grade II/VI systolic flow murmur

Physical Exam

Lungs: Clear to Auscultation Bilaterally Abdominal Exam: Hypoactive BS, mildly

distended, soft, diffusely tender but without rebound or guarding

Rectal: no external anal lesions, heme + stools

Extremities: trace pedal edema

Differential DiagnosisWould you like to update your differential?

Laboratory

What would you obtain?

Lab Results

VBG: 7.35/35/40 AG= 10 Lactate: 1.1 Cultures and Stool Studies

pending

8.9

2811.2

PMN’s =80% MCV = 80.1 LFTs WNL PT/PTT normal

300140 111

2.9 18

37

1.3

Laboratory Results-Discussion

Leukocytosis – consistent with inflammation, could indicate infection

Anemia – indicative of blood loss, likely acute on chronic blood loss given low MCV

Mild Non-anion gap Metabolic Acidosis with appropriate respiratory compensation – seen in the context of diarrhea

Hypokalemia – GI losses and volume depletion

Interventions at this point?

Consider the following Immediate Interventions

Admit to Hospital NPO Fluid Resuscitation with Isotonic

Crystalloid• (NS, LR, or Plasmalyte) Correct Electrolyte Abnormalities Stop any narcotic, antidiarrheal, or

anticholinergic agents Begin IV Corticosteroids

Studies

Do you want any further studies?

Abdominal X-Ray

Abdominal X-ray Discussion

Dilated Colon Toxic Megacolon

• Dilation of Transverse or Ascending Colon >6cm• No small bowel pathology

Colonoscopy

Colonoscopy findings

Fulminant Colitis• Friable, Ulcerated Mucosa

• Mucosal Edema and Erythema

• Hemorrhagic

Colonoscopy - Discussion

Generally avoided during fulminant presentations of colitis

May be used cautiously to determine presence of ischemic or pseudomembranous colitis

Minimize insufflation used Should not be performed when there is

colonic dilation and is contraindicated for cases of toxic megacolon

Abdominal CT (not necessary)

Abdominal CT - Interpretation

Severe Colitis• Diffuse Colonic Wall Thickening with

Submucosal Edema

• Pericolic Stranding

• Ascites

Medical Management of Severe Ulcerative Colitis

Cyclosporine• Calcineurin inhibitor• Administer 2-4mg/kg/day as continuous IV infusion

if patient not responding to IV corticosteroids

Infliximab• Monoclonal antibody to TNFα• Administered as IV infusion

Hospital Course

Symptoms do not improve on steroids and cyclosporine

She continues to experience bloody diarrhea and worsening abdominal pain.

Final Diagnosis

Ulcerative Colitis complicated by Fulminant Colitis with Toxic Megacolon

What next?

Management

Continue Supportive Therapy Medical Management

• Broad spectrum antibiotics – will treat any infectious component and also offer coverage should perforation occur

• Continue IV corticosteroids

Bowel Decompression may be considered when colon is dilated using Rectal Tube

Prepare for Surgery

Indications for Surgery

Perforation Uncontrolled Bleeding Progressive Dilation Worsening Symptoms Failure to Improve with Medical Management within

24 hours

* Delay in surgical intervention leading to emergent surgery is associated with increased morbidity and mortality.

Surgical Options

Subtotal Colectomy and End Ileostomy (leaving rectal stump)• Avoid the prolonged procedure of total proctocolectomy

and extensive pelvic dissection• Each may be followed by elective restoration of bowel

continuity and pouch construction at a later date

Total Proctocolectomy with Ileal Pouch–Anal Anastomosis (IPAA)• rarely performed during fulminant presentations due to

high incidence of morbidity• increased rate of reoperation and anastomotic

complications

Subtotal Colectomy

Remove diseased colon Create ileostomy Allow toxic state to resolve Restorative proctocolectomy with ileal pouch–anal

anastomosis (IPAA) at a later date

Discussion Serious Complications of fulminant presentations of

Ulcerative Colitis include:• Massive Hemorrhage• Perforation• Toxic Megacolon

Toxic Megacolon is defined as colonic distension >6cm in the presence of an active inflammatory process.

Though most commonly associated with IBD, toxic megacolon may also complicate infectious colitis including Pseudomembranous colitis.

Discussion

Diagnosis

• There may be a history of Ulcerative Colitis, but approximately 10% of patients will present initially with fulminant colitis.

• History usually includes cramping abdominal pain, increased bowel movements, and stool mixed with blood and mucous.

• There is often leukocytosis, anemia, and electrolyte disturbances.

Discussion

Diagnosis• If toxic megacolon occurs, dilated colon will be

visible on abdominal x-ray and CT. CT is a good non-invasive modality for identifying subclinical complications of fulminant colitis such as perforations and abscesses.

• Colonoscopy should be used with care when disease is active and is contraindicated if colon is dilated or patient has fulminant colitis

Discussion

Management• Non-surgical management includes aggressive fluid

resuscitation, correction of electrolyte abnormalities, administration of broad spectrum antibiotics, and in the case of IBD (ulcerative colitis or Crohn’s disease), administration of corticosteroids

• Additional medical management may include immune modulator therapy with cyclosporine or infliximab

• Colonic decompression for dilated colon may be employed

Discussion

Management• Surgery is indicated when signs and symptoms fail

to improve with medical management or worsen • Emergent Surgery is also warranted in the setting of

perforation, hemorrhage, progressive dilation or toxic megacolon.

• Surgical Management, consists of subtotal colectomy with end-ileostomy for emergency situations and must be pursued aggressively when indicated as delay leads to increased morbidity and mortality

QUESTIONS ??????

References Baumgart DC, Sandborn WJ. “Inflammatory Bowel Disease: clinical aspects

and evolving therapies.” Lancet. 2007;369:1641-57. Cima, RR and Pemberton JH. “Surgical Indications and Procedures in

Ulcerative Colitis.” Current Treatment Options in Gastroenterology. 2004;7:181-190

Modigliani, R. “Medical Management of Fulminant Colitis.” Inflammatory Bowel Diseases. 2002;8(2):129-134.

Bullard KM, Rothenberger DA. “Colon, Rectum & Anus.” Schwartz's Principles of Surgery. 8th Edition.

S. Ian Gan and P.L. Beck. “A New Look at Toxic Megacolon: An Update and Review of Incidence, Etiology, Pathogenesis, and Management.” The American Journal of Gastroenterology. 2003;98(11):2364-2371.

Rüssmann H, Panthel K, Bader RD, Schmitt C, Schaumann R. “Evaluation of three rapid assays for detection of Clostridium difficile toxin A and toxin B in stool specimens.” Eur J Clin Microbiol Infect Dis. 2007 Feb;26(2):115-9

Strong, Scott. “Fulminant Colitis: the case for operative management.” Inflammatory Bowel Diseases. 2002;8(2):135-137.

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